Healthcare Provider Details

I. General information

NPI: 1588471452
Provider Name (Legal Business Name): AMANDA THAYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HARRINGTON ST
MOUNT CLEMENS MI
48043-2920
US

IV. Provider business mailing address

340 W 10TH ST STE 6200
INDIANAPOLIS IN
46202-3082
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-3095
  • Fax:
Mailing address:
  • Phone: 317-274-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number39
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: